A Nonhealing or Intransigent Phase of a Septic Wound Ulcer on the Left Lower Limb for Over 30 Years without Clinical Diabetes: A Case Report
DOI:
https://doi.org/10.12970/2310-998X.2021.09.04Keywords:
Acute and chronic wounds, Septic ulcer, lower limbs, arterial revascularization, debridement, organogenesis dressing, amputationAbstract
Chronic nonhealing wounds are painful with both psychological and financial cost to the affected patient tied to extensive economic repercussion on society. Here, we present a case of a 54-year-old man who has been living with a painful nonhealing septic ulcer wound for more than 30 years. Clinical examination revealed an extensive septic ulcerative wound on the lower left extremity with multiple ulcerative lesions covering the peroneus brevis, digitorum longus and the foot with erythema and oedema. Doppler scan revealed femoral arteries with thick veins that had undergone 25% stenosis. The left popliteal vein had 25% stenosis with distal obstruction to blood flow with elevated peaks of systolic velocity whiles the posterior tibial artery showed a reduced flow with abnormal waveform and an intraluminal plaque formation of about 50% stenosis. This chronic nonhealing wound requires a more sophisticated wound healing intervention such as arterial revascularisation, debridement, treatment with antimicrobials and organogenesis dressing to permit wound healing.
References
Aldridge P. Wound healing: recognising what's normal. Companion Animal 2015; 20(4): 222-8. https://doi.org/10.12968/coan.2015.20.4.222
Dunnill C, Patton T, Brennan J, Barrett J, Dryden M, Cooke J, Leaper D, Georgopoulos NT. Reactive oxygen species (ROS) and wound healing: the functional role of ROS and emerging ROS‐modulating technologies for augmentation of the healing process. International Wound Journal 2017; 14(1): 89-96. https://doi.org/10.1111/iwj.12557
Saghazadeh S, Rinoldi C, Schot M, Kashaf SS, Sharifi F, Jalilian E, Nuutila K, Giatsidis G, Mostafalu P, Derakhshandeh H, Yue K. Drug delivery systems and materials for wound healing applications. Advanced Drug Delivery Reviews 2018; 127: 138-66. https://doi.org/10.1016/j.addr.2018.04.008
Velnar T, Bailey T, Smrkolj V. The wound healing process: an overview of the cellular and molecular mechanisms. Journal of International Medical Research 2009; 37(5): 1528-42. https://doi.org/10.1177/147323000903700531
Whitney JD. Overview: acute and chronic wounds. Nursing Clinics 2005; 40(2): 191-205. https://doi.org/10.1016/j.cnur.2004.09.002
Eming SA, Martin P, Tomic-Canic M. Wound repair and regeneration: mechanisms, signaling, and translation. Science Translational Medicine 2014; 6(265): 265sr6. https://doi.org/10.1126/scitranslmed.3009337
Enoch S, Leaper DJ. Basic science of wound healing. Surgery (Oxford) 2005; 23(2): 37-42. https://doi.org/10.1383/surg.23.2.37.60352
Cash JL, Martin P. Myeloid cells in cutaneous wound repair. Microbiology Spectrum 2016; 4(3): 4-3. https://doi.org/10.1128/microbiolspec.MCHD-0017-2015
Hussain Z, Thu HE, Katas H, Bukhari SN. Hyaluronic acid-based biomaterials: a versatile and smart approach to tissue regeneration and treating traumatic, surgical, and chronic wounds. Polymer Reviews 2017; 57(4): 594-630. https://doi.org/10.1080/15583724.2017.1315433
Prasetyono TO. General concept of wound healing, revisited. Medical Journal of Indonesia 2009; 18(3): 208-16. https://doi.org/10.13181/mji.v18i3.364
Sarah AH, Ardeshir B. Soft and Hard Tissue Repair. InScott-Brown’s Otorhinolaryngology Head and Neck Surgery. CRC Press 2018; pp. 93-105. https://doi.org/10.1201/9780203731031-10
Singh S, Young A, McNaught CE. The physiology of wound healing. Surgery (Oxford) 2017; 35(9): 473-7. https://doi.org/10.1016/j.mpsur.2017.06.004
Broderick N. Understanding chronic wound healing. The Nurse Practitioner 2009; 34(10): 16-22. https://doi.org/10.1097/01.NPR.0000361299.88402.f6
Gaspar-Pintiliescu A, Stanciuc AM, Craciunescu O. Natural composite dressings based on collagen, gelatin and plant bioactive compounds for wound healing: A review. International Journal of Biological Macromolecules 2019; 138: 854-65. https://doi.org/10.1016/j.ijbiomac.2019.07.155
Sephel GC, Woodward SC. Repair, regeneration, and fibrosis. Rubin’s Pathology 2001; 84-117.
Atiyeh BS, Ioannovich J, Al-Amm CA, El-Musa KA. Management of acute and chronic open wounds: the importance of moist environment in optimal wound healing. Current Pharmaceutical Biotechnology 2002; 3(3): 179-95. https://doi.org/10.2174/1389201023378283
Sen CK, Gordillo GM, Roy S, Kirsner R, Lambert L, Hunt TK, Gottrup F, Gurtner GC, Longaker MT. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair and Regeneration 2009; 17(6): 763-71. https://doi.org/10.1111/j.1524-475X.2009.00543.x
Schultz GS, Ladwig G, Wysocki A. Extracellular matrix: review of its roles in acute and chronic wounds. World Wide Wounds 2005; 2005: 1-8.
Goldman R. Growth factors and chronic wound healing: past, present, and future. Advances in Skin & Wound Care 2004; 17(1): 24-35. https://doi.org/10.1097/00129334-200401000-00012
Demidova-Rice TN, Hamblin MR, Herman IM. Acute and impaired wound healing: pathophysiology and current methods for drug delivery, part 1: normal and chronic wounds: biology, causes, and approaches to care. Advances in Skin & Wound Care 2012; 25(7): 304. https://doi.org/10.1097/01.ASW.0000416006.55218.d0
Guo SA, DiPietro LA. Factors affecting wound healing. Journal of Dental Research 2010; 89(3): 219-29. https://doi.org/10.1177/0022034509359125
Rowan MP, Cancio LC, Elster EA, Burmeister DM, Rose LF, Natesan S, Chan RK, Christy RJ, Chung KK. Burn wound healing and treatment: review and advancements. Critical Care 2015; 19(1): 1-2. https://doi.org/10.1186/s13054-015-0961-2
Parkar, Hafiza. "Wound healing potential of Terminalia sericea." PhD diss., University of Pretoria, 2016.
Xie T, Ye J, Rerkasem K, Mani R. The venous ulcer continues to be a clinical challenge: an update. Burns & Trauma 2018; 6. https://doi.org/10.1186/s41038-018-0119-y
Jaar BG, Astor BC, Berns JS, Powe NR. Predictors of amputation and survival following lower extremity revascularization in hemodialysis patients. Kidney International 2004; 65(2): 613-20. https://doi.org/10.1111/j.1523-1755.2004.00420.x
Klein TM, Andrees V, Kirsten N, Protz K, Augustin M, Blome C. Social participation of people with chronic wounds: A systematic review. International Wound Journal 2020. https://doi.org/10.1111/iwj.13533
Hartoch RS, McManus JG, Knapp S, Buettner MF. Emergency management of chronic wounds. Emergency medicine clinics of North America 2007; 25(1): 203-21. https://doi.org/10.1016/j.emc.2007.01.010
Järbrink K, Ni G, Sönnergren H, Schmidtchen A, Pang C, Bajpai R, Car J. The humanistic and economic burden of chronic wounds: a protocol for a systematic review. Systematic Reviews 2017; 6(1): 1-7. https://doi.org/10.1186/s13643-016-0400-8
McGuckin M, Waterman R, Brooks J, Cherry G, Porten L, Hurley S, Kerstein MD. Validation of venous leg ulcer guidelines in the United States and United Kingdom. The American Journal of Surgery 2002; 183(2): 132-7. https://doi.org/10.1016/S0002-9610(01)00856-X
Ma H, O'Donnell Jr TF, Rosen NA, Iafrati MD. The real cost of treating venous ulcers in a contemporary vascular practice. Journal of Vascular Surgery: Venous and Lymphatic Disorders 2014; 2(4): 355-61. https://doi.org/10.1016/j.jvsv.2014.04.006
Luz AR, de Moura Vergara R, Mourão MS. Lower Limb Ulcers. InVascular Diseases for the Non-Specialist. Springer, Cham 2017; pp. 203-220. https://doi.org/10.1007/978-3-319-46059-8_17
Hess CT, Kirsner RS. Orchestrating wound healing: assessing and preparing the wound bed. Advances in Skin & Wound Care 2003; 16(5): 246-57. https://doi.org/10.1097/00129334-200309000-00015
Cho H, Blatchley MR, Duh EJ, Gerecht S. Acellular and cellular approaches to improve diabetic wound healing. Advanced Drug Delivery Reviews 2019; 146: 267-88. https://doi.org/10.1016/j.addr.2018.07.019
Gallant‐Behm CL, Piper J, Dickinson BA, Dalby CM, Pestano LA, Jackson AL. A synthetic microRNA‐92a inhibitor (MRG‐110) accelerates angiogenesis and wound healing in diabetic and nondiabetic wounds. Wound Repair and Regeneration 2018; 26(4): 311-23. https://doi.org/10.1111/wrr.12660
Cheng F, Eriksson JE. Intermediate filaments and the regulation of cell motility during regeneration and wound healing. Cold Spring Harbor Perspectives in Biology 2017; 9(9): a022046. https://doi.org/10.1101/cshperspect.a022046
Fletcher J. Differences between acute and chronic wounds and the role of wound bed preparation. Nursing Standard (through 2013) 2008; 22(24): 62. https://doi.org/10.7748/ns2008.02.22.24.62.c6412
Boateng J, Catanzano O. Advanced therapeutic dressings for effective wound healing—a review. Journal of Pharmaceutical Sciences 2015; 104(11): 3653-80. https://doi.org/10.1002/jps.24610
Kirk RM, Winslet MC. Essential general surgical operations. Elsevier Health Sciences 2007.
Widgerow AD. Deconstructing the stalled wound. Wounds: a Compendium of Clinical Research and Practice 2012; 24(3): 58-66.
Segerstrom SC, Miller GE. Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychological Bulletin 2004; 130(4): 601. https://doi.org/10.1037/0033-2909.130.4.601
Landén NX, Li D, Ståhle M. Transition from inflammation to proliferation: a critical step during wound healing. Cellular and Molecular Life Sciences 2016; 73(20): 3861-85. https://doi.org/10.1007/s00018-016-2268-0
Chrisman CA. Care of chronic wounds in palliative care and end‐of‐life patients. International Wound Journal 2010; 7(4): 214-35. https://doi.org/10.1111/j.1742-481X.2010.00682.x
Weitz JI, Byrne J, Clagett GP, Farkouh ME, Porter JM, Sackett DL, Strandness DE, Taylor LM. Diagnosis and treat-ment of chronic arterial insufficiency of the lower extremities: a critical review. Circulation 1996; 94(11): 3026-49. https://doi.org/10.1161/01.CIR.94.11.3026
Armstrong PA, Bandyk DF. Duplex scanning for lower extremity arterial disease. InNoninvasive Peripheral Arterial Diagnosis. Springer, London 2010; pp. 47-55. https://doi.org/10.1007/978-1-84882-955-8_5
Salles-Cunha SX, Andros G. Preoperative duplex scanning prior to infrainguinal revascularization. Surgical Clinics of North America 1990; 70(1): 41-59. https://doi.org/10.1016/S0039-6109(16)45032-2
Cragg AH, Dake MD. Percutaneous femoropopliteal graft placement. Journal of Vascular and Interventional Radiology 1993; 4(4): 455-63. https://doi.org/10.1016/S1051-0443(93)71898-9
Gerhard-Herman M, Creager MA. Vascular laboratory testing. Vascular Medicine: A Companion to Braunwald's Heart Disease E-Book: A Companion to Braunwald's Heart Disease 2019; 152.
Powers JG, Higham C, Broussard K, Phillips TJ. Wound healing and treating wounds: Chronic wound care and management. Journal of the American Academy of Dermatology 2016; 74(4): 607-25. https://doi.org/10.1016/j.jaad.2015.08.070
Gould LJ, Abadir PM, White-Chu EF. Age, frailty, and impaired wound healing. Principles and Practice of Geriatric Surgery 2020; 465-82. https://doi.org/10.1007/978-3-319-47771-8_27
Clemens MW, Parikh P, Hall MM, Attinger CE. External fixators as an adjunct to wound healing. Foot and Ankle Clinics 2008; 13(1): 145-56. https://doi.org/10.1016/j.fcl.2007.12.001
Kret MR, Cheng D, Azarbal AF, Mitchell EL, Liem TK, Moneta GL, Landry GJ. Utility of direct angiosome revascularization and runoff scores in predicting outcomes in patients undergoing revascularization for critical limb ischemia. Journal of Vascular Surgery 2014; 59(1): 121-8. https://doi.org/10.1016/j.jvs.2013.06.075
MacNeil S. Progress and opportunities for tissue-engineered skin. Nature 2007; 445(7130): 874-80. https://doi.org/10.1038/nature05664
Rennert RC, Rodrigues M, Wong VW, Duscher D, Hu M, Maan Z, Sorkin M, Gurtner GC, Longaker MT. Biological therapies for the treatment of cutaneous wounds: phase III and launched therapies. Expert Opinion on Biological Therapy 2013; 13(11): 1523-41. https://doi.org/10.1517/14712598.2013.842972
Zaulyanov L, Kirsner RS. A review of a bi-layered living cell treatment (Apligraf®) in the treatment of venous leg ulcers and diabetic foot ulcers. Clinical Interventions in Aging 2007; 2(1): 93. https://doi.org/10.2147/ciia.2007.2.1.93
Greaves NS, Iqbal SA, Baguneid M, Bayat A. The role of skin substitutes in the management of chronic cutaneous wounds. Wound Repair and Regeneration 2013; 21(2): 194-210. https://doi.org/10.1111/wrr.12029
Thangapazham RL, Darling TN, Meyerle J. Alteration of skin properties with autologous dermal fibroblasts. International Journal of Molecular Sciences 2014; 15(5): 8407-27. https://doi.org/10.3390/ijms15058407
Date CE. Bioengineered Skin and Soft Tissue Substitutes. HMO 2019; 2000: 06-18.
Sibbald RG, Torrance GW, Walker V, Attard C, MacNeil P. Cost-effectiveness of Apligraf in the treatment of venous leg ulcers. Ostomy/Wound Management 2001; 47(8): 36-46.
Bakri FG, Allan AH, Khader YS, Younes NA, Ajlouni KM. Prevalence of diabetic foot ulcer and its associated risk factors among diabetic patients in Jordan. J Med J 2012; 46(2): 118-25.
Ollendorf DA, Kotsanos JG, Wishner WJ, Friedman M, Cooper T, Bittoni M, Oster G. Potential economic benefits of lower-extremity amputation prevention strategies in diabetes. Diabetes Care 1998; 21(8): 1240-5. https://doi.org/10.2337/diacare.21.8.1240
